2022-02-01 Ex 01Exhibit 1
2/1 /2022
Pagel of 3
Revised 3/5/19
CITY OF OKEECHOBEE
55 SE THIRD AVENUE
OKEECHOBEE, FL 34974
Tele: 863-763-9821 Fax: 863-763-1686
PARK USE AND/OR TEMPORARY STREET/
SIDEWALK CLOSING
PERMIT APPLICATION
Date Received:
Date Issued:
A2plication No:
Date(s) & Times of Event: Friday, February 18, 2022 6am-2:30pm
Information:
Organization: Okeechobee Christian Academy
Mailing Address: 701 S. Parrott Ave, Okeechobee, FL 34974
Contact Name: Melissa King
E-Mail Address: Melissa.King@OkeechobeeChristianAoademy.org
Telephone:
Work: 863-763-3072 1 Home: I I Cell
Summary of activities:
Students will participate in Field Day and will need to cross back and forth all day.
Proceeds
Please check requested Parks:
Flagler Parks: ❑ City Hall Park ❑ #1 Memorial Park o #2 ❑ #3 ❑ #4 o #5 ❑ #6
[Park 3 is location of Gazebo. Park 4 is location of Bandstand]
(If other private property used in conjunction with this Park Use Permit please provide the address and
parcel number below along with notarized letter of authorization from property owner)
Additional Addresses, if applicable
Parcel ID:
Page 2 of 3
Revised 3/5/19
TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION
(Street Closings require City Council approval. Meetings V & 3`d Tuesdays but subject to change)
Address of Event: 701 S Parrott Ave
Street(s) to be closed: SE 2nd Ave from SE 6th Street to SE 7th Street
Date(s) to be closed: Friday, February 18, 2022
Time(s) to be closed:8:00am-2:30pm
Purpose of Closing: Safety of children crossing the street
Attachments Required for Use of Parks Attachments Remiirerl fnr 4QtrPPt/C'ir1awa1L- i'ineinno
► Site Plan
► Site Plan
► Copy of liability insurance in the amount of
► Copy of liability insurance in the amount of $1,000,000.00
$1,000,000.00 with the City of Okeechobee as
with the City of Okeechobee and R.E. Hamrick Testamentary
additional insured.
Trust as Additional Insured.
► Proof of non-profit status
► Original signatures of all residents, property owners and
business owners affected by the closing.
► State Food Service License if > 3 days.
► State Food Service License if > 3 days.
► Notarized letter of authorization from
► State Alcoholic Beverage License, if applicable.**
property owner, if applicable.*
Required it private property used in conjunction with a Park Use application.
** Alcoholic beverages can be served only on private property. Alcoholic beverages NOT ALLOWED in City
Parks, City streets or City sidewalks. See additional note below.
❑ Please check if items will be sold on City streets/sidewalks. Each business will need to apply for a Temporary
Use Permit 667 along with the Street Closing application.
Note:
► Clean-up is required within 24 hours.
► No alcoholic beverages permitted on City property, streets or sidewalks.
► No donations can be requested if any type of alcoholic beverages are served on private
property/business unless you possess a State Alcoholic Beverage License. Please note there are inside
consumption and outside consumption licenses. You must have the appropriate license(s).
► The Department of Public Works will be responsible for delivering the appropriate barricades.
► Dumpsters and port-o-lets are required when closing a street for more than three (3) hours.
Applicant must meet any insurance coverage and code compliance requirements of the City and other regulations
of other governmental regulatory agencies. The applicant will be responsible for costs associated with the event,
including damage of property. By receipt of this permit, the applicant agrees and shall hold the City harmless for
any accident, injury, claim or demand whatever arises out of applicant's use of location for such event, and shall
indemnify and defend the City for such incident, including attorney fees. The applicant shall be subject to
demand for, and payment of, all of the actual costs incurred by the City pertaining to the event including, but not
limited to, Police, Fire, Public Works or other departmental expenses. The City reserves the right to require from
an applicant a cashier's check or advance deposit in the sum approximated by the City to be incurred in providing
City services. Any such sum not incurred shall be refunded to the applicant of this Park Use/Street Closing
Permit.
Page 3 of 3
Revised 3/5/19
I hereby acknowledge that I have read and completed this application, the attached Resolutions No.(s) 03-8 and
04-03, concerning the use and the rules of using City property, that the information is correct, and that I am the
duly authorized agent of the organization. I agree to conform with, abide by and obey all the rules and
regulations, which may be lawfully prescribed by the City Council of the City of Okeechobee, or its officers, for
the issuance
Certificate of Insurance must name City of Okeechobee as Additional Insured as well as R.E. Hamrick
Testamentary Trust if closing streets or sidewalks.
Applicant Signature
Staff Review
1 /12/2022
Date
••••OFFICE USE ONLY••••
Fire Department:
Date:
Building Official:
Date:
Public Works:
Date:
Police Department:
Date:
BTR Department:
Date:
City Administrator:
Date:
City Clerk:
Date:
NOTE: APPLICATION AND INSURANCE CERTIFICATE MUST BE COMPLETED AND
RETURNED TO THE GENERAL SERVICES DEPARTMENT THIRTY (30) DAYS PRIOR TO
EVENT FOR PERMITTING.
Temporary Street and Sidewalk Closing submitted for review by City Council on
Temporary Street and Sidewalk Closing reviewed by City Council and approved
Date
Date
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.acoRci CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYYY)
03/31/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement- A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
JDA Insurance Group
120 N. Federal Hwy., #301
CONTACT Christine Dewey
PHONE (561) 296-0373 PAX (561) 828-0997
E.t ac, No
E-MAILo
g p' ADDRESS: rou Christine@ the'da com
INSURER(S) AFFORDING COVERAGE
NAIC #
Lake Worth FL 33460
INSURERA: Philadelphia Indemnity Insurance Company
18058
INSURED
INSURER B : Insurance Company of the West
27847
Okeechobee Christian Academy, Inc.
INSURER C :
701 South Parrott Ave
INSURER D :
INSURER E :
Okeechobee FL 34974
INSURER F:
CuVERAuEs CERTIFICATE NUMBER: CL2183100816 RFVISIr1M MIIMRFR-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
NSD
WVD
POLICYNUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MMIDDr(YY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
S 1,000,000
CLAIMS -MADE OCCUR
PREMISES Ea occurrence
$ 500,000
MED EXP (Anv one Derson)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000.000
A
Y
PHPK2268175
07/01/2021
07/01/2022
LIMITAPPLIES PER:
GENERAL AGGREGATE
S 3,000,000
GEN'LAGGREGATE
X
POLICY JE❑LOC
3,000,000
S-O/OGG
S
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
S 1,000,000
Ea accldenl
ANYAUTO
BODILY INJURY (Per person)
$
A
OWNED SCHEDULED
AUTOS ONLY AUTOS
PHPK2266175
07/01/2021
07/01/2022
BODILY INJURY (Per accldenl)
S
XHIRED
�/ NON -OWNED
/�
PROPERTY DAMAGE
S
AUTOS ONLY AUTOS ONLY
Per accldenl
X
UMBRELLA LIAR
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE
$ 1,000.000
A
EXCESS LIAe
PHUB765957
07/01/2021
07/01/2022
AGGREGATE
$ 1,000,000
DED x RETENTION S 10.000
Products-Comp/Op Agg
S 1,000,000
WORKERS COMPENSATION
��// PER OTH-
X I
AND EMPLOYERS' LIABILITY YIN
STATUTE I ER
E.L. EACH ACCIDENT
S 1,000.000
B
ANY PROPRIETORIPARTNERIE'ECUTIVE El
OFFICER/MEMBER EXCLUDED.
WFL504202103
07/02/2021
07/02/2022
E.L. DISEASE - EA EMPLOYEE
S 1,000,000
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
Professional Liability
Each Claim
$1,000,000
A
PHPK2282925
07101/2021
07/01/2022
Aggregate
$1,000,000
Retention
$1,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Re: With respect to field day events for the school
The City of Okeechobee and R.E. Hamrick Testamentary Trust is named as an Additional Insured under the General Liability policy evidenced herein.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of Okeechobee ACCORDANCE WITH THE POLICY PROVISIONS.
R.E. Hamrick Testamentary Trus
55 SE 3rd Ave AUTHORIZED REPRESENTATIVE
Okeechobee FL 34974-2903�'�
U 19BB-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Gail Neu
From: Melissa King <melissa.king@okeechobeechristianacademy.org>
Sent: Wednesday, January 12, 2022 12:10 PM
To: Gail Neu
Subject: Request for Street Closing on 2/18/2022
Attachments: Field Day closing 01222022.pdf
Good afternoon and Happy New Year!
Please find attached our request for a street closing on 2/18/2022 to be added to the next City Council meeting.
Thank you so much.
Mrs. Melissa King
Principal
863-763.3072 Office
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